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In this research paper, I want to explore the reasons for spreading HIV/AIDS and difficulties faced by HIV/AIDS patients in Pakistan.  For this research I have reviewed the published and second hand literature to obtain the available data on HIV/AIDS in Pakistan. I have searched the electronic databases and read the books provided by LUMS Library. I picked this topic i.e. HIV/AIDS, because people feel reluctant in talking about such diseases and there is a social taboo that patients of AIDS must have done illicit sexual discourse and are thus socially shunned by the relatives and friends. Also, this virus is a recently spread one in Pakistan and mostly people are unaware of this disease and feel fear in discussing sex related topics with families and life partners. In the end, I would tell that what are those difficulties and how those difficulties can be overcome and government and non-government organizations can provide an appropriate treatment to the Pakistani people.

Human Immunodeficiency Virus (HIV) is a virus which attacks on the immune system of the individual and makes it so weak that it cannot resist the weakest attack by any germ or bacteria and leads to the death of that individual. HIV can spread through the use of contaminated syringes, blades, improper screened blood transfusion, unprotected sex with male (MSW, HSW)or female and also from an infected mother to child and infected husband to the wife. (Altaf, Abbas, Zaheer; 2008).

HIV/AIDS in Pakistan carries a negative connotation and people think that AIDS can only be spread through illegal sex and thus are reluctant in discussing sexual health issues in open because of the social taboo. Being a Muslim country, people in Pakistan consider sex a big fault in religious terms, HIV is mostly considered in Pakistan caused through illicit sexual discourse which makes people reluctant to share their views and even patients from seeking the treatment. This helped the virus in spreading more easily through the community and effected many people in Pakistan.
Social Context:
Pakistan and its people is the subject of my research. Pakistan is situated in South Asia, towards its east is India, in north is China, in north-west is Afghanistan and in west is Iran. Pakistan is a developing country and is struggling for its welfare and a place in the list of developed countries. A large portion of Pakistani population is still unaware of HIV/AIDS, especially in rural areas.  Religious, social and cultural factors impact on HIV/AIDS patients, in acquiring a quality treatment and their survival in such a conservative society like Pakistan. These factors also play a vital role in spreading this disease and not letting people get the appropriate treatment and also keeping them unaware of the precautionary measurements like safe sex, using of sterilized blades and syringes.
 Pakistan has recently found this virus in its Injection Drug Users (IDUs), according to the reports HIV first found in 2003 and its ratio increased to 31% in 2007, in Karachi (HIV/AIDS Surveillance Project; 2006-7).

     The issue of HIV/AIDS prevention in Pakistan is a complex problem and requires a multifaceted approach with particular attention to cultural norms. In order to revise harm reduction strategies for HIV prevention in Pakistan, it is important to study the social dynamics and practices of the populations at risk.

Philipson and Posner [19] note that human actors make rational choices aimed at maximizing the expected utility of the outcome. The subjective welfare of the actor and presence of uncertainty are two inherent components of expected utility maximization. When acquiring information is costly, an uninformed choice – one that underestimates or overestimates the risk to health of some contemplated action – may still be expected utility maximization. Therefore, when education and counseling services are not readily and cheaply available, or when accessing such services means that the user has to disclose risk behaviors and is afraid to do so, he/she has no course but to make uninformed decisions. Effective counseling and education have been shown to change sexual behavior and reduce the risk of HIV transmission even in high risk groups.

The Pakistan National AIDS Program (NAP) was set up in 1987 by federal government, assisted by donor agencies, to coordinate HIV/AIDS surveillance and control activities (8,12). The NAP has established HIV testing centers in the country and screened more than one million people (10 15). Despite these important contributions, the data regarding HIV/AIDS in Pakistan has not been utilized effectively to inform proactive health policy. While activities at the provincial level, particularly in the province of Sindh have been productive, the other provinces have not followed as rapidly (8).
In 1995, the four provinces of Pakistan were encouraged to form their own AIDS control programs with support from federal government. However, political issues and disagreements over program components have resulted in disparate success in the provinces. However a decade has passed since the recognition of HIV in country, groups at higher risk have been identified but still there are certain challenges and hurdles which are creating difficulty for the government as well as non-government organizations to offer a proper treatment and awareness regarding HIV/AIDS in Pakistan and also playing a significant role in spreading the disease across the community. These hurdles are education, economic conditions, misconception or low information regarding AIDS, gender inequality, stigma and discrimination.

Challenges faced by HIV/AIDS Patients and Reasons for spreading of HIV/AIDS:
              In the Muslim World, religion defines culture and the culture gives meaning to every aspect of an individual's life. Being a Muslim country, Pakistan has also a culture defined by Islam and has influenced each and every aspect of individual’s life. Following are the reasons for spreading of HIV/AIDS and are challenges and hurdles came across the appropriate treatment provided by governmental and non-governmental organizations in Pakistan, which need particular attention when designing HIV prevention programs for Pakistan:

1: Gender Inequality:
In Pakistani society, there is imbalanced power between men and women, which is apparent in heterosexual relations as well as in the economic and social spheres of life – with men having greater power than women. For most women, the private life within the sanctuary of their houses is their whole life. Due to such cultural settings of Pakistan, women remain uneducated and deprived of resources, unaware of their civil, legal and sexual rights, economically dependent on men. Due to these inequalities, women are more susceptible to contracting HIV/AIDS as they are less likely to be able to negotiate with their partners infected with HIV/AIDS. Women also are easy targets for abusive relationships and are less able to cope with illness once infected.

2: Stigma and Discrimination:
The social stigma attached to HIV/AIDS that exists in all societies is much more pronounced in Muslim cultures due to the religious doctrine regarding illicit sex and drug related practices. There are greater negative sanctions for sexual conduct than drug use. Even if there is a suspicion of illicit sexual conduct, the affected person(s) is discriminated against and shunned by the family as well as by the community. This stigma and discrimination attached to HIV/AIDS, discourages people from coming forward for appropriate counseling, testing and treatment, as this would involve disclosure of their risky practices. This results in creating barriers to successful implementation of prevention and treatment strategies where they do exist.

3: Ignorance/Misinformation:
In developed countries, a majority of the population is aware of the modes of transmission for HIV infection, whereas in the developing countries, misconceptions about the disease and its causes are prevalent. Most of the Pakistani population consider that all HIV infections are transmitted only through immoral sexual behaviors and are unaware that it can also be transmitted frequently through mother-to-child, accidental pricking of skin and contact with contaminated blood (as in the case of health care professionals) or the possibility of an innocent spouse getting infected by the husband who may have acquired HIV though sexual or drug related contact with other infected persons. Therefore, due to lack of information and misconception regarding HIV/AIDS, lead to acquiring and spreading the infection and also deprive people from getting an appropriate care and treatment.

4: Poverty and Economic Condition:
About one third of the total population of Pakistan live below the poverty line and economic conditions of Pakistani population are getting worsen day by day because of low job opportunity and low business markets of Pakistan. Poor people in Pakistan cannot afford the costly treatment or diagnosis of the disease. People living in rural areas do not even afford the travelling cost to urban cities in search of appropriate treatment. Poverty and poor economic condition of Pakistani population create difficulty for them to acquire a quality treatment for the HIV/AIDS.

5: Internal Conflicts:
Now a day Pakistan is facing many internal conflicts like Taliban, suicide bombing and Shia-Sunni conflict in Chitral (Emma Varley’s article). In conflicted zone, medical facilities get affected in many ways; difficulty in mobility or reaching in hospitals, availability of doctors, peaceful place to carry out the treatment, limited supply of medical equipment and medicines. Hospitals and doctors both get affected from such conflicts and senior or experienced doctors do not go into such conflicted areas.
6: Social Taboo:
Due to the social taboo in Pakistan, people feel shame or fear while talking about topics relating to sexual health in Pakistan. Also marriage partners cannot share their experiences regarding such diseases and women due to patriarchal society cannot go herself to seek the treatment because she is dependent upon her husband and her husband in return also don’t step forward to take care of her due to the social taboo that men never poke their nose in female health problem.

7: Other Issues:
            In addition to the issues outlined above, the main challenges to instituting an HIV prevention approach include, wars, refugees, migrant labor forces, intimidating role of religious leaders and activists, and lack of healthcare resources and infrastructure.
Social, religious and cultural barriers in Pakistan are the major hurdles for Pakistani people to acquire an appropriate diagnosis and treatment for HIV/AIDS. While a cautious approach will be suitable initially, giving proper information regarding the symptoms and adding some basic information in the educational syllabus of early education and social awareness regarding the symptoms, precautions and treatment of HIV/AIDS. 
I have come across the reasons for spreading and challenges faced by HIV/AIDS patients through my secondary research are social, cultural and religious factors. These reasons and challenges can be removed or overcome by taking proper steps towards the removal of HIV/AIDS completely from Pakistan. Those steps are that people with AIDS should not be shunned or socially out casted from the community but should be treated with more care and affection and should not let feel alone. As HIV/AIDS is a life threatening disease, patients of HIV/AIDS feel more psychologically stressed because they afraid from being publically known, leading to be shunned by their friends, family and society from the community. They are fighting at the same time with themselves as well as with the community and during this fight they lose their life.   
In the context of HIV/AIDS prevention and treatment in Pakistan, the principles of harm reduction or harm minimization can certainly be utilized to prevent or minimize the spread of HIV infection. However, a clear distinction needs to be made that this approach does not advocate illicit drug and sex related practices. The harm reduction concept can be applied to other high risk groups, such as commercial sex workers (MSW, HSW, and FSW). Because consistent condom use has been linked to reductions in HIV seroincidence [15,20,21], and because reductions in frequency of unprotected sex also predict lower levels of HIV infection incidence, the behavioral effects of the intervention carry considerable public health importance. In addition to counseling, IDUs could be provided needles at reduced prices or even free of charge. Regular screenings for HIV/AIDS should make significant contributions to HIV prevention, early detection, and appropriate treatment where required.

Written By: Saqib Rehman

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